Resuscitation Policy This procedural document supersedes: PAT/EC 1 v.7- Resuscitation Policy Did you print this document yourself? The Trust discourages the retention of hard copies of policies and can only guarantee that the policy on the Trust website is the most up-to-date version. If, for exceptional reasons, you need to print a policy off, it is only valid for 24 hours. Author/reviewer: (this version) Date written/revised: February 2014 Lisette Caygill Lead- Resuscitation Officer Dr Jonathan Allen-Resuscitation Committee Chairperson Approved by: Resuscitation Committee 4 March 2014 Ratified by: Policy Approval and Compliance Group 19 March 2014 Date issued: 26 March 2014 Next review date: February 2017 extended to September 2017 Target audience: Trust wide Page 1 of 24
Amendment Form Please record brief details of the changes made alongside the next version number. If the procedural document has been reviewed without change, this information will still need to be recorded although the version number will remain the same. Version Date Issued Brief Summary of Changes Author Version 8 26 March 2014 References updated Terms of reference updated Test bleep procedure added Procedure for calling for an ambulance in an emergency at MMH/Retford hospital OR outside of the main hospital complex Monitoring compliance updated Appendix 3 PAWS charts included Appendix 4 Resuscitation Teams updated L Caygill J Allen Version 7 November 2010 Major changes throughout - PLEASE READ IN FULL. L Caygill Version 6 August 2007 Page 4 Objectives Pages 5, item 1 Immediate Action Pages 5/6, item 2 Members of the Cardiac Arrest Team Page 6/7, item 3 Resuscitation Equipment Pages 7-10, item 4 Training Page 10, item 6 Audit Pages 11-14, items 7/8 Specialist Areas Page 17, Appendix 2 Pages 19-34, Appendix 4 Algorithms Page 35, Appendix 5 Resuscitation Event Record Page 36/37, Appendix 6 Medical Equipment Training & Fault Reporting Page 38, Appendix 7 Cardiac arrest occurring in an area where a defibrillator is not currently available Version 5 August 2006 Page 5, item 4 Training Page 6, item 5 Resuscitation of New-born and Paediatrics Page 13 Retford L Caygill K Pears Resuscitation Committee Page 2 of 24
Section Contents 1 Introduction 4 2 Purpose 4 3 Duties and Responsibilities 4 4 Procedure 5 5 Training/Support 9 6 Monitoring Compliance with the Procedural Document 11 7 Definitions 11 8 Equality Impact Assessment 12 9 Associated Trust Procedural Documents 12 10 References 12 Appendices Appendix 1 Resuscitation Committee Terms of Reference 14 Appendix 2 Early Warning System (EWS) 16 Appendix 3 Paediatric Advanced Warning Score (PAWS) 17 Appendix 4 Emergency Teams 23 Page No. Page 3 of 24
1. INTRODUCTION This resuscitation policy fully supports the Quality Standards for Cardiopulmonary Resuscitation Practice and Training in Acute Care published by the Resuscitation Council (UK) (2013). http://www.resus.org.uk/pages/qscpr_acute.htm 2. PURPOSE The purpose of the policy is to provide direction and guidance for the planning and implementation of a high-quality and robust resuscitation service to Doncaster & Bassetlaw Hospitals NHS Foundation Trust (here after referred to as the Trust). The strategy for resuscitation incorporates the current published guidelines for resuscitation (Resuscitation Council (UK), 2010). http://www.resus.org.uk/pages/gl2010.pdf 3. DUTIES AND RESPONSIBILITIES The Trust has an obligation to provide an effective resuscitation service to their patients and appropriate training to their staff. A suitable infrastructure is required to establish and continue support for these activities. 3.1 Duties within the Organisation It is the responsibility of the Chief Executive to designate responsibility to a non-executive Director of the Trust to ensure that a resuscitation policy is agreed, implemented and regularly reviewed within the clinical governance framework (Health services Circular 2000/028). It is the responsibility of the Resuscitation Committee, Lead Resuscitation Officer and Policy Coordinator to ensure policy distribution, implementation and compliance throughout the organisation. It is the responsibility of Clinical Service Unit Managers and Matrons to ensure that staff are provided with the opportunity to attend training appropriate to their role. It is the responsibility of individual staff members to attend training appropriate to their roles. Page 4 of 24
3.2 Approval of the Resuscitation Policy The policy has been approved by the Resuscitation Committee (Appendix 1) and is ratified in accordance with the Policy Approved Procedural Documents (APDs) Development and Management Process - CORP/COMM 1. 3.3 Scope of Policy This policy applies to all clinical staff and those with direct patient contact. 4. PROCEDURE 4.1 The Early Warning System The early warning system (EWS), has been established for use with all patients to identify those who are clinically deteriorating and require urgent intervention, which may prevent cardiopulmonary arrest. All clinical staff should be trained in the identification of critically ill patients and the use of Trust generic observation charts which incorporates EWS, to enhance decision-making and care escalation if required. Staff should initiate the early warning score (EWS) protocol (see appendix 2) to provide early identification of patients at risk of cardio respiratory arrest. The paediatric advanced warning score (PAWS) system should be used for all paediatric patients. The associated charts are age specific and should be used accordingly. (see appendix 3). 4.2 Composition of the cardiac arrest team The composition of the respective emergency teams (Adult / Paediatric / Obstetric) is detailed within Appendix 4. 4.3 Cardiac Arrest Calls All Trust and temporary staff must familiarise themselves with the layout of the hospital to enable a rapid response in emergency situations. In the event of a cardiac arrest / medical / obstetric or neonatal emergency the appropriate emergency team must be alerted immediately. The emergency telephone number is 2222. This number should be used in the following circumstances: Cardiac arrest Paediatric cardiac arrest Page 5 of 24
Neonatal emergency team Obstetric emergency team Maternal cardiac arrest call cardiac arrest team and obstetric emergency team Fast bleep (name specific individual required, i.e. on-call medical registrar) Trauma team Fire Security The precise location of the patient must be communicated promptly and clearly to the switchboard operator (do not use old names/locations). The switchboard operator will activate all emergency bleeps simultaneously via a speech channel. Each member of the appropriate emergency team must respond at his or her earliest opportunity to this call. All emergency calls are logged by switchboard. 4.4 Response to 2222 calls Cardiac arrest/emergency calls take precedence over all other activities unless the cardiac arrest bleep holder is already involved in another life threatening procedure. If a team member becomes indisposed they must inform switchboard immediately and arrange for a member of staff of at least equal ability to carry their cardiac arrest bleep. Switchboard should be notified as soon as the situation returns to normal. 4.5 Cancelling 2222 calls If the cardiac arrest team is no longer required, staff should dial 2222 and request the cardiac arrest call to (state location) be cancelled. This will then be sent via the speech channel to all emergency bleeps. 4.6 Test Bleeps The Trust must ensure that the resuscitation team is activated within 30 seconds of the call for help. This system must be tested daily. Responses to test calls must be monitored and where there is a failure to respond this must be followed up and remedied immediately. 4.7 Cardiac Arrests occurring at Mexborough Montagu Hospital/ Retford Hospital OR outside Main Buildings across the Trust If a cardiac arrest or other medical emergency occurs in any location at MMH/Retford Hospital or outside of the main hospital complex across the Trust, a (9) 999 call should be made to Page 6 of 24
request a paramedic ambulance. Any member of staff attending a casualty should provide first aid/ resuscitation according to their skills and ability in conjunction with any available equipment. 4.8 Cardiac Arrest Trolleys Standardised sealed adult and paediatric cardiac arrest trolleys are in place at DRI, BDGH and MMH sites. Following the use of a cardiac arrest trolley, replacement equipment should be sought immediately. At DRI, BDGH and MMH sites a trolley exchange system is in place via main theatres. All other Trust sites are responsible for the replenishment of used equipment to ensure the immediate availability of a cardiac arrest trolley at all times. 4.9 Post Resuscitation Care After initial resuscitation, the patient may require further specific treatment. The resuscitation team leader and the patient s own medical team should dictate subsequent management. This may involve transfer to another area e.g. DCC/CCU. 4.10 Patient transfer Transfer should only take place after discussion with senior members of the admitting team. To ensure safe transfer it is essential to consider the following; stabilisation, continued monitoring, securing of all cannulae, drains, tubes and catheters, and good communication skills. The transfer team must be able to respond to other emergencies, including cardiac arrest or subsequent deterioration whilst moving the patient. A full re-assessment MUST take place prior to transfer. Portable suction, oxygen and other essential equipment must accompany the patient and transfer team. 4.11 Maintenance of Resuscitation Equipment It is the responsibility of the ward/department manager to ensure that all resuscitation equipment and supplies are checked at least once every 24 hours, and following the use of equipment to replenish supplies. The expiry dates on all accessible items should be checked, including drugs and disposable items. A list should be kept of equipment and a record signed stating ALL equipment is present and functioning correctly. Page 7 of 24
4.12 Defibrillators Defibrillators are serviced regularly by Medical Technical Services (ext. 3558). If a defibrillator malfunctions, it should be reported immediately to Medical Technical Services, removed from service and temporarily replaced with the spare defibrillator located in the equipment library. If this defibrillator is unavailable, clinical areas should share defibrillators until the problem is resolved. Defibrillators must not be removed from the resuscitation training unit to replace malfunctioning machines. It is the responsibility of the nurse/person in charge to inform all relevant staff of the situation and ensure that they know the location of the defibrillator to be used in the event of cardiac arrest. Defibrillators are only suitable for cardiac monitoring in the peri-arrest situation and should not be used for routine monitoring. If prolonged cardiac monitoring is necessary, the patient should be transferred to a suitable area, where they can be observed by appropriately trained staff. 4.13 Drugs The contents of the cardiac arrest drug packs are in accordance with current Resuscitation Council (UK) guidelines for the treatment of cardio respiratory arrest. 4.14 Manual Handling When resuscitating a patient who is on the floor, in a chair, or other confined space, the Trust guidelines for patient movement should be followed. The objective of this is to minimise the risks of manual handling and related injuries to all parties. 4.15 Cross Infection Although the risk of infection transmission from patient to rescuer during direct mouth-tomouth resuscitation is extremely rare, isolated cases have been reported. It is therefore advisable that direct mouth-to-mouth resuscitation be avoided in the following circumstances: All patients who are known to have or suspected of having an infectious disease All undiagnosed patients entering the Accident & Emergency department, Outpatients or other admission source Other persons where the medical history is unknown All clinical areas should have immediate access to airway devices so that mouth-to-mouth ventilation is not necessary. In situations where airway protective devices are not immediately available, chest compressions should commence whilst awaiting an airway device. Page 8 of 24
4.16 Anaphylaxis The management of suspected anaphylaxis should be conducted in accordance with Trust policy Emergency Treatment of Anaphylaxis Policy and Guidelines (PAT/EC 3) and with the Resuscitation Council (UK) Guidelines. http://www.dbh.nhs.uk/library/patient_policies/pat%20ec%203%20v.5%20- %20Anaphylaxis%20Policy%20-%20final.pdf 4.17 Procurement All resuscitation equipment purchasing is subject to the organisation s standardisation strategy; therefore the Resuscitation Service must sanction all resuscitation equipment prior to ordering. During any future development of services/building redesign/relocation, early advice should be sought from Resuscitation Services regarding procurement of additional/new resuscitation equipment. 4.18 Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) The Trust s DNACPR Policy complies with the guidance issued by the BMA / RCN / Resuscitation Council (UK) (2007), the General Medical Council s guidance on Treatment and care towards the end of life: good practice in decision making (2010) and the Resuscitation Council (UK) Quality standards for cardiopulmonary resuscitation practice and training- acute care (2013). http://www.resus.org.uk/pages/dnar.htm http://www.gmc-uk.org/guidance/ethical_guidance/end_of_life_care.asp http://resus.org.uk/pages/qscpr_acute.htm 5. TRAINING/ SUPPORT The strategy for resuscitation training shall embody the statements and guidelines published by the Resuscitation Council (UK) and the European Resuscitation Council, incorporating the most recent updates to these guidelines. This explicitly incorporates the identification of patients at risk from cardiac arrest and a strategic approach to implement preventative measures such as Early Warning Systems. The Trust will provide sufficient and appropriate resuscitation training for each of the main staff groups. Profession specific resuscitation training will be directed by their respective functional role and the guidelines and directives issued by their professional bodies (e.g. The Royal College of Anaesthetists). Levels of training appropriate to role are detailed in the Trust Mandatory & Statutory Policy CORP/EMP 29. Page 9 of 24
The approach to teaching is one of positive encouragement and proven educational efficacy which follows the recommendations for resuscitation teaching advocated by the Resuscitation Council (UK) (Mackay-Jones & Walker, 1998). 5.1 Training recommendations All newly appointed trust employees must receive training as part of their induction programme. ALL staff must know how to summon help using the emergency system (2222) and be made aware of the location of emergency equipment. 5.2 Clinical Staff All doctors, nurses, midwives and Allied Health Professionals must be adequately and regularly trained in cardiopulmonary resuscitation appropriate to their discipline. The level of that training is determined by their respective professional bodies and / or the duties that those staff would be expected to undertake when in attendance at a cardiac arrest / medical / obstetric / neonatal emergency. It is the responsibility of departmental managers to ensure that any of his/her clinical and clinical support staff attend training appropriate to their role. Training and facilities must ensure that, when cardiorespiratory arrest occurs, as a minimum all clinical staff can: Recognise cardiorespiratory arrest Summon help Start CPR Attempt defibrillation, if appropriate, within 3 minutes of collapsing using an automated external defibrillator or manual defibrillator Clinical staff should have at least annual updates. 5.3 Non-clinical Staff As a minimum, non-clinical staff should be trained to: Recognise cardiorespiratory arrest Summon help Start CPR using chest compressions 5.4 Training Records Resuscitation Services are responsible for updating individual staff records of attendance at resuscitation training (delivered by Resuscitation Officers) on the Oracle learning management (OLM) system. Training delivered by approved link trainers will be inputted locally. All certified Page 10 of 24
resuscitation training that has been successfully completed at an external course centre should also be recorded. 6. MONITORING COMPLIANCE WITH THE PROCEDURAL DOCUMENT. MONITORING COMPLIANCE WITH THE PROCEDURAL UMEN What is being Monitored Cardiac arrest reviews of management & escalation Equipment Audit Who will carry out the Monitoring Resuscitation Services will monitor reviews completed at ward level. Resuscitation Services Weekly How often Annually with re audit for non compliance How Reviewed/ Where Reported to Reported monthly to Trust Board. Reported quarterly to the Resuscitation Committee, Review of Mortality Group and Patient Safety Review Group Reported annually to the Resuscitation Committee, CD s, GM s, Matrons, ward managers and Patient Safety Review Group 7. DEFINITIONS Advanced Life Support Use of all basic life support techniques with added intervention of drugs, defibrillation and other mechanical devices acting on the patients cardiac rhythm and output. Anaphylaxis Anaphylaxis is a severe life-threatening, generalised or systemic hypersensitivity reaction. Investigations will show whether the reaction is allergic (immunoglobulin E (IgE) or non lge mediated) or non-allergic anaphylaxis. Basic Life Support External chest compressions and ventilation with the use of airways, face masks, bag-valve-mask systems and oxygen in any combination. Cardiac Arrest Cardiac arrest may be defined as the abrupt cessation of cardiac function that is potentially reversible. Defibrillation Defibrillation is the passage of electrical current across the myocardium to depolarise a critical mass of the cardiac muscle simultaneously to enable the natural pacemaker to resume control. Page 11 of 24
Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) A clinical decision not to commence cardiopulmonary resuscitation. 8. EQUALITY IMPACT ASSESSMENT An Equality Impact Assessment (EIA) has been conducted on this procedural document in line with the principles of the Equality Analysis Policy (CORP/EMP 27) and the Fair Treatment For All Policy (CORP/EMP 4). The purpose of the EIA is to minimise and if possible remove any disproportionate impact on employees on the grounds of race, sex, disability, age, sexual orientation or religious belief. No detriment was identified. A copy of the EIA is available on request from the HR Department. 9. ASSOCIATED TRUST PROCEDURAL DOCUMENTS Do Not Attempt Resuscitation (DNAR) Policy - PAT/EC 2 Manual handling Policy - CORP/HSFS 04 Mental Capacity Act 2005 Policy and Procedure - PAT/PA 19 Physiological Observations: policy for adult in-patients in acute hospitals - PAT/T 33 Policy and Guidelines for the Emergency Treatment of Anaphylaxis - PAT/EC 3 Privacy and Dignity Policy - PAT/PA 28 Standard Infection Control Precautions Policy - PAT/IC 19 Trust Mandatory & Statutory Policy - CORP/EMP 29 10. REFERENCES General Medical Council (2010) Treatment and care towards the end of life: good practice in decision making. MacKay - Jones, K. and Walker, M. (1998) Pocket Guide to Teaching for Medical Instructors. BMJ Books. London Mental Capacity Act 2005 Department of Health Page 12 of 24
Resuscitation Policy. Health Services Circular (HSC) 2000/028. London. Department of Health Resuscitation Council (UK) (2001) Guidance for Safer Handling during Resuscitation in Hospital Resuscitation Council (UK) (2007) Decisions Relating to Cardiopulmonary Resuscitation. A Joint Statement from the British Medical Association, the Resuscitation Council (UK) and the Royal College of Nursing. Resuscitation Council (UK) (2010) Resuscitation Guidelines 2010. http://www.resus.org.uk/siteindx.htm Resuscitation Council (UK) (2013) Quality Standards for Cardiopulmonary Resuscitation Practice and Training- Acute Care. Page 13 of 24
APPENDIX 1 Resuscitation Committee TERMS OF REFERENCE 1. INTRODUCTION The Resuscitation Committee is a multi- disciplinary committee who report to the Clinical Governance Standards Committee via the Patient Safety Review Group. 2. PURPOSE AND OBJECTIVES The purpose of this committee is: 1. To monitor and evaluate the clinical service provided to the Trust regarding all resuscitation related issues. 2. To report quarterly to the Patient Safety Review Group regarding cardiac arrest figures and outcomes including case note review classifications and annually to the Clinical Governance Standards Committee. 3. To support the Resuscitation Service. 4. To provide specialist knowledge/advice in all aspects of resuscitation to this Trust to facilitate the review, development and approval of all resuscitation related Approved Procedural Documents (APD). 3. COMMUNICATION The Lead Resuscitation Officer will report activity to PSRG on a quarterly basis. All resuscitation related APD s will be approved by the resuscitation committee and taken to Policy Approval & Compliance Group for final ratification. 4. MEMBERSHIP The committee will be led by the Chairperson nominated via the committee for an initial term of 3 years subject to approval by the Trust Medical Director. In the absence of the Chairperson the Lead Resuscitation Officer will assume this responsibility. The committee will work as a team and individual actions will be identified after each meeting and recorded in the minutes. The committee shall consist of the following members:- Nominated Chairperson Lead Resuscitation Officer Resuscitation Officers Page 14 of 24
Senior clinical representation from: A&E Anaesthetics Medicine Medicine for older people & specialist palliative care Paediatrics Theatres Midwifery Surgery Orthopaedics Pharmacy 5. MEETINGS AND ATTENDANCE The meetings will be scheduled for two hours quarterly. Attendance is required at all meetings. Members unable to attend should indicate in writing or by e-mail to the Resuscitation Services administrator in advance of the meeting (except in extenuating circumstances of absence). Members are advised to nominate a deputy to attend who is appropriately briefed to participate in the meeting. Members (or a designated deputy) should attend at least 3 meetings throughout a calendar year. 6. QUORUM The quorum is 2 Clinicians plus 4 other members (not including the Resuscitation Services team) to be present at the start of the meeting. 7. ADMINISTRATION The committee administrator s duties include: Drafting of the agenda, and circulating the associated documents at least 1 week before the meeting. Produce minutes with actions from each meeting. Produced by: Lisette Caygill - Lead Resuscitation Officer Date written: 16 th October 2013 Approved/ratified by : Resuscitation Committee Date approved: 16 th October 2013 For review: October 2016 Page 15 of 24
APPENDIX 2 The Early Warning Score (EWS) Algorithm IPOC 701 In circumstances where the patient s condition deteriorates rapidly, a cardiac arrest call should also be made. Page 16 of 24
APPENDIX 3 Page 17 of 24
Page 18 of 24 PAT/EC 1 v.8
Page 19 of 24 PAT/EC 1 v.8
Page 20 of 24 PAT/EC 1 v.8
Page 21 of 24 PAT/EC 1 v.8
Page 22 of 24 PAT/EC 1 v.8
APPENDIX 4 EMERGENCY TEAMS Adult Resuscitation Team members DRI and BDGH Anaesthetist (Core Trainee) (if available) Medical Registrar & SHO on-call Operating Department Practitioner (ODP) Clinical Site Manager Resuscitation Officer (when available) Ward Staff MMH & RETFORD HOSPITAL No cardiac arrest team call 999 DRI Anaesthetist Registrar (if available) Paediatric Registrar & SHO on-call Paediatric bleep holder Operating Department Practitioner (ODP) Clinical Site Manager Resuscitation Officer (when available) Ward Staff BDGH Anaesthetist 1 st on call (if available) Paediatric Registrar & SHO on call Operating Department Practitioner (ODP) Paediatric bleep holder Clinical Site Manager Resuscitation Officer (when available) Ward Staff Paediatric Resuscitation Team Members Page 23 of 24
Obstetric Emergency Team DRI Obstetric Registrar & SHO on call Anaesthetist (based in Women s & Children s Hospital) Operating Department Practitioner (ODP) Senior Duty Midwife BDGH Bleep holders are contacted individually via switchboard. Page 24 of 24